Abstract P3-15-04: A French prospective pilot study to identify dihydropyrimidine dehydrogenase (DPD) deficiency in breast cancer patients receiving capecitabine

Background: Health Authorities point out that DPD deficiency confers a significant risk of major toxicity for patients receiving capecitabine. Identification of at-risk patients is thus of major concern. This multicentric prospective study of the French GPCO group (Groupe de Pharmacologie Clinique Oncologique, Unicancer) evaluated the sensitivity, specificity and predictive values of DPD phenotyping and genotyping to predict severe cap-related toxixity in metastatic breast cancer patients.

Methods: 303 patients were included between February 2009 and February 2011 (15 institutions). Eighty-eight% received capecitabine as monotherapy, 28% were treated as first line (mean dose at 1st cycle 1957 mg/m2/d). Pre-treatment uracil (U, physiological DPD substrate) plasma concentration was measured in 286 patients (HPLC assay). DPD genotyping (IVS14+1G>A, 2846A>T, 1679T>G, 464T>A) was performed on 281 patients. Severe toxicity (G3-4 CTCAE v3 criteria) was measured over cycles 1-2.

Results: Grade 3-4 toxicity (diarrhea, vomiting, hematoxicity, hand-foot syndrome) has been observed in 19.6% of patients (one toxic death). A marked trend for higher U concentrations has been noted in patients developing severe toxicity vs those who didn't (median 12.7 ng/ml (Q1-Q3 9-17) vs median 10.2 ng/ml (range 8-13), respectively, p = 0.014). However, ROC curve has showed that this difference was too small for use as a reliable toxicity predictor. The patient with toxic death had an elevated U concentration at 17 ng/ml. Among the 7 patients with a DPD mutation (3 pts IVS14+1, 3 pts 2846A>T, one 1679T>G, all heterozygous), 5 developed severe toxicity (including the toxic death, 2846A>T), one did not, and the last one was not documented. Relative risk for developing severe toxicity was 4.60 in mutated patients vs wild-type patients (95%CI 2.95-7.16, p = 0.001); positive and negative predictive values were 83.3% and 81.9%, respectively; specificity was 99.5% and sensitivity was 9.8%.

Conclusions: Breast cancer patients harbouring a DPD variant allele are at risk to develop severe, up to lethal, capecitabine-related toxicity. Pre-treatment U measurement remains to be more firmly established as a reliable predictor of capecitabine toxicity. These observations are of major interest for breast cancer patients candidate for capecitabine therapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-15-04.

Abstract P3-13-07: A-TaXel: Multicenter phase II combination of bevacizumab (A) with weekly paclitaxel (Ta) and capecitabine (Xel) in first line treatment for patients with triple negative metastatic or locally advanced breast cancer (TNMBC), a GINECO study

Background: Weekly paclitaxel and capecitabine intermittent regimen is a safe and effective combination in first line treatment of MBC including triple negative cancer (Lortholary et al, Breast Cancer Res Treat 2012). In TNMBC, the combination of A with first line Ta or Xel has been shown to improve response rate (RR) and progression-free survival (PFS) (Miller K et al., N Engl J Med 2007, Robert J et al., J Clin Oncol 2011). This phase II study is to evaluate the efficacy and safety of A-TaXel combination in TNMBC.

Methods: Patients (pts) with measurable TNMBC were treated in first line until progression with q28 cycles of Ta (80 mg/m2 D1, 8, 15) + Xel (800 mg/m2 bid D1-5, 8-12, 15-19) + A (10 mg/kg D1, 14). Primary end point was best overall RR; secondary were safety, PFS, response duration and overall survival (OS).

Results: From 04/2010 to 03/2012, 64 pts were accrued including 2 ineligible pts. Patients characteristics were: median age (56.7 yrs), ECOG PS 0 (55%), histological grade III (61%), previous adjuvant chemotherapy (74%), visceral disease (65%), > 1 metastatic sites (74%).

Patients received a median of 6 cycles (1-6), mean 5.1. Grade 3-4 neutropenia, anemia and thrombopenia were 23%, 4% and 16% respectively with febrile neutropenia in 5% of pts. G-CSF support was observed in 7% of cycles. Most frequent non hematologic toxicities were alopecia (gr2 40%), hand-foot syndrome (gr2 27%, gr3 13%), nail toxicity (gr2 40%), hypertension (gr3 35%), neuropathy (gr2 26%, gr3 6%), mucositis (gr2 16%, gr3-4 9%), fatigue (gr3 18%, gr4 2%), nausea (gr2 15%, gr3 2%) and thrombosis (gr2 3%, gr3-4 5%). Treatment interruption due to toxicity was 22%, DPD deficiency in one patient, hospitalization 23%.

RR was 77%, CR 19%, PR 58%, stable disease 14% and progressive disease 9%. Median response duration was 5.6 months. Median PFS was 7.9 months (6.7-9) and OS 19.2 months (17.3-21.1).

Conclusion: A-TaXel is an effective regimen with high RR and manageable toxicity.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-13-07.

A randomized clinical trial of adjuvant chemotherapy with doxorubicin, ifosfamide, and cisplatin followed by radiotherapy versus radiotherapy alone in patients with localized uterine sarcomas (SARCGYN study). A study of the French Sarcoma Group

BACKGROUND

There is no proven benefit of adjuvant treatment of uterine sarcoma (US). SARCGYN phase III study compared adjuvant polychemotherapy followed by pelvic radiotherapy (RT) (arm A) versus RT alone (arm B) conducted to detect an increase ≥ 20% of 3-year PFS.

METHODS

Patients with FIGO stage ≤ III US, physiological age ≤ 65 years; chemotherapy: four cycles of doxorubicin 50 mg/m² d1, ifosfamide 3 g/m²/day d1-2, cisplatin 75 mg/m² d3, (API) + G-CSF q 3 weeks. Study was stopped because of lack of recruitment.

RESULTS

Eighty-one patients were included: 39 in arm A and 42 in arm B; 52 stage I, 16 stage II, 13 stage III; 53 leiomyosarcomas, 9 undifferenciated sarcomas, 19 carcinosarcomas. Gr 3-4 toxicity during API (/37 patients): thrombopenia (76%), febrile neutropenia (22%) with two toxic deaths; renal gr 3 (1 patient). After a median follow-up of 4.3 years, 41/81 patients recurred, 15 in arm A, 26 in arm B. The 3 years DFS is 55% in arm A, 41% in arm B (P = 0.048). The 3-year overall survival (OS) is 81% in arm A and 69% in arm B (P = 0.41).

CONCLUSION

API adjuvant CT statistically increases the 3 year-DFS of patients with US.

BAYPAN study: a double-blind phase III randomized trial comparing gemcitabine plus sorafenib and gemcitabine plus placebo in patients with advanced pancreatic cancer

BACKGROUND

Sorafenib is an oral anticancer agent targeting Ras-dependent signaling and angiogenic pathways. A phase I trial demonstrated that the combination of gemcitabine and sorafenib was well tolerated and had activity in advanced pancreatic cancer (APC) patients. The BAYPAN study was a multicentric, placebo-controlled, double-blind, randomized phase III trial comparing gemcitabine/sorafenib and gemcitabine/placebo in the treatment of APC.

PATIENTS AND METHODS

The patient eligibility criteria were locally advanced or metastatic pancreatic adenocarcinoma, no prior therapy for advanced disease and a performance status of zero to two. The primary end point was progression-free survival (PFS). The patients received gemcitabine 1000 mg/m(2) i.v., weekly seven times followed by 1 rest week, then weekly three times every 4 weeks plus sorafenib 200 mg or placebo, two tablets p.o., twice daily continuously.

RESULTS

Between December 2006 and September 2009, 104 patients were enrolled on the study (52 pts in each arm) and 102 patients were treated. The median and the 6-month PFS were 5.7 months and 48% for gemcitabine/placebo and 3.8 months and 33% for gemcitabine/sorafenib (P = 0.902, stratified log-rank test), respectively. The median overall survivals were 9.2 and 8 months, respectively (P = 0.231, log-rank test). The overall response rates were similar (19 and 23%, respectively).

CONCLUSION

The addition of sorafenib to gemcitabine does not improve PFS in APC patients.

A phase I study of UFT-oral vinorelbine in metastatic breast cancer

BACKGROUND

Despite current treatment options, metastatic breast cancer (MBC) remains essentially incurable, requiring research on new drugs or combinations to improve survival and quality of life.

PATIENTS AND METHODS

This phase I study was designed to define the maximum-tolerated dose (MTD), dose-limiting toxicity (DLT) and recommended dose of all-oral tegafur-uracil (UFT)/folinic acid combined with vinorelbine as chemotherapy for MBC. Starting doses were 40 mg/m(2)/week of oral vinorelbine administered continuously and 250 mg/m(2)/day of UFT plus 90 mg/day of folinic acid from day 1 to day 28, followed by a 1-week rest period.

RESULTS

Ten patients were included. Eight were evaluable for toxicity and antitumor response. The second dose level was shown to be the MTD. At this dose, 2 out of 5 patients receiving oral vinorelbine at 40 mg/m(2)/week and UFT at 300 mg/m(2)/day developed DLT consisting of grade 3 asthenia and grade 3 nausea despite standard prophylaxis. Other toxicities were grade 1 diarrhea and anemia. There were no treatment-related deaths.

CONCLUSIONS

The recommended dose for this combination seems to be the first dose level. A stable response was observed for 6 patients (average 33 weeks). This combination appears to be well-tolerated and offers an alternative to intravenous chemotherapy.

Docetaxel and pegylated liposomal doxorubicin combination as first-line therapy for metastatic breast cancer patients: results of the phase II GINECO trial CAPYTTOLE

BACKGROUND

This phase II study evaluated the clinical benefit of pegylated liposomal doxorubicin (PLD) and docetaxel (Taxotere) as first-line therapy for metastatic breast cancer (MBC).

PATIENTS AND METHODS

MBC patients were enrolled to receive six cycles of PLD 35 mg/m2 (day 1) and docetaxel 40 mg/m2 (days 1 and 15), every 28 days (group A). Because of unacceptable toxic effects, doses were modified to PLD 30 mg/m2 (day 1) and docetaxel 75 mg/m2 (day 2), every 3 weeks (group B). The primary end point was clinical benefit.

RESULTS

Sixty-seven patients were included (group A, 53; group B, 14). In both groups, the median number of cycles delivered was 4 and the overall dose intensity was 82% for docetaxel and 71% for PLD. In group A, main toxic effects were hematologic, palmar-plantar erythrodysesthesia (PPE), and stomatitis. In group B, higher rates of grade 3-4 PPE, febrile neutropenia, and hematologic toxic effects were reported. The rate of clinical benefit was 47%. Among patients with a measurable disease, 49% achieved a partial response, 27% had a stable disease, and 13% progressed, according to RECIST criteria.

CONCLUSION

The combination of PLD and docetaxel delivered at planned doses in this study yields unacceptable toxicity and should not be used routinely in patients with MBC.

Distal or proximal venous port device insertion: Results of a prospective randomized trial

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Background: Open, nonblinded, prospective, randomized, controlled trial comparing two techniques of venous port device insertion: percutaneous distal (phlebography-guided arm port- study technique- 2) vs proximal surgical (cephalic vein cutdown- control technique- 1) placement -To determine whether technique 1 is superior to technique 2. Methods: 230 eligible patients beginning a course of i.v. chemotherapy via a port device catheter with an expected duration of treatment of 3 months or longer were randomized (written informed consent). Eligibility criteria included adult patients with solid tissue malignancy (neuro oncology, gynecology, lung, abdominal, head§neck) beginning a course of I.V.chemotherapy, normal hemostatic parameters, no organ failure, a life expectancy >3months, WHO status<3. Exclusion criteria included current anticoagulant therapy, previous ipsilateral venous catheter/pacewires/surgical axillary node dissection/radiodermatitis, local tumor growth/sepsis, symptomatic brain metastasis, psychosis. The silicone rubber 7F catheter was connected to a 11mm port reservoir, and implanted under local anesthesia using either technique 1 or 2 after randomization. Outcome measurements included technical feasibility/procedure duration, port complications, quality of life (EORTC) questionnaires. Results: Median study duration was 12.2 vs 11.9 months (p: 0.9), median chemotherapy cycles were 6.0 in both groups. Patients groups differed significantly in venous access side (left access in group 2) and sex ratio (p=0.028). In group 2, technical success rate was higher (99 vs 91%, p<0.02), procedure was shorter: 18.0min (10.0–90.0) vs 21min (15.0- 45.0)(p<0.008), but global complication rate was higher (p<0.05). Device complication related explantation rate was 11.9 vs 2.8% (p=0.022). Conclusions: Both techniques are safe and effective. Despite a higher technical success rate and a shorter procedure duration, arm port insertion has a lower complication-free duration. Distal (arm port) technique should be recommended in young female cancer patients (neckline cosmesis/discretion), head and neck cancer patients, obese patients (upright position) and in patients presenting with respiratory insufficiency or at high risk for pneumothorax.

No significant financial relationships to disclose.

Weekly paclitaxel and capecitabine in HER2-negative metastatic breast cancer (MBC): A multicenter GINECO randomized phase II comparing two paclitaxel-capecitabine schedules

1114

Background: Paclitaxel (Ta) and capecitabine (Xel) are synergistic in vitro. Compared to a continuous weekly Tax combined with a classical 14 days (d)/21 Xel administration (Elza-Brown et al., ASCO 2000), we have explored the combination of Xel 5d/week (wk) and weekly Ta 3 wk out 4 in the objective to increase the efficacy/toxicity ratio of the TaXel combination. Methods: Patients (pts) in first or second-line of MBC, previously treated with anthracyclins + docetaxel were randomized either to A: Ta (60 mg/m2/w) + Xel (2000 mg/m2/d x 14 d/21) or to B: Ta (80 mg/m2/w) + Xel (2000 mg/m2/d x 5 d/wk) 3wk out 4. Results: From January 2006 to January 2008, 130 pts were accrued (A 66, B 64). Pts characteristics were well balanced between the two arms including median age (58 yrs), histologic type and grade, hormone receptor-positive tumor (80%), previous treatment, visceral disease (72%), number of sites (>1; 63%), ECOG PS (0; 42%, 1; 58%). Pts received a median of 6 cycles (1–23) with a received/planned mean dose of 89.3% for Ta in both arms and of 74 and 76% for Xel respectively in arm A and B. Haematological toxicity (Tox) was low in both arms with neutropenia Gr 3 in only 8% of cycles, G-CSF support in 2% of cycles, and infection G3 in 5 pts. Alopecia G2 was less frequent in arm A (29 vs 60%). Other Tox were similar in both arms: [G2/3 (%) cutaneous (35/17), pain (36/9), fatigue (26/13), neuropathy (20/3), diarrhea (15/6), mucositis (8/2), vomiting (9/1)] but treatment interruption due to Tox was more frequent in A (A 19, B 7 pts) (p = 0.02). Response rate was 52% (B) versus 44% (A). A progression-free survival advantage was seen for B over A (366 vs 272 days, p = 0,15) including in the triple negative pt subset (n = 26 pts) (197 vs 150 days, p = 0.07). Conclusions: The intermittent regimen (3 wk out 4) of weekly paclitaxel and capecitabine 5 d/week is a well accepted, safe and effective TaXel schedule and might be a chemotherapy regimen of choice in MBC including triple negative patients.

No significant financial relationships to disclose.

Weekly paclitaxel (wP) as single agent or in combination with weekly topotecan (wT) or carboplatin (C) in patients with resistant ovarian cancer (ROC): The phase II CARTAXHY randomized trial from GINECO

5557

Background: For ROC patients (pts) with early progression during or after (< 6 months) platinum and 3 weekly P, use of single non-platinum agent including wP is standard (Kristensen G, et al. J Clin Oncol 26: 2008 abstr 5508). Few randomized trials have explored combination therapy in this setting. Methods: Pts with ROC after a first or second line including a platinum and a taxane were randomized to receive wP (80 mg/m2/week) alone or in combination with wT (3mg/m2/week) or C (AUC 5 every 4 weeks). The primary end-point was the comparison of progression-free survival (PFS) between single non-platinum agent and combination therapy (wP+wT or wP+C). Secondary objectives included safety, QoL, response rate (RR) and overall survival. Results: From April 2004 to August 2008, 165 pts were accrued (wP 57, wP+wT 57, wP+C 51). Median number of cycles and P dose-intensity (mg/m2/week) was 4.6 and 70, 4.2 and 63 in monotherapy and combination therapy arms respectively. Non-hematological toxicity was not different between the arms, except an excess of hypersensitivity reactions in the wP+C arm. Grade 3–4 neutropenia (48 vs 13% of pts), and anemia (24 vs 6%) were more frequent in combination therapy than in single agent arm and similar with wT or C combination. Febrile neutropenia was experienced by 5 pts treated with combination therapy. Discontinuation from drug treatment was more frequent with combination therapy (24% of pts) than with monotherapy (4%), mainly due to hematotoxicity. RR was 34, 38 and 39% for wP, wP+wT and wP+C respectively. Median PFS of pts treated with single agent (112 days) was not significantly different from those treated with combination therapy (149 days) (p = 0,62) and was similar in wP+wT (152 days) or wP+C (146 days) arms. Treatment with single non-platinum agent or combination therapy was not found an independent parameter when added to a Cox model including prognostic variables. Conclusions: Combination therapy (CT) in platinum resistant ovarian cancer was found more toxic than weekly paclitaxel and the PFS advantage from CT was not statistically significant.

No significant financial relationships to disclose.

Aromatase inhibition in male breast cancer patients: Biological and clinical implications

1130

Background: Because male breast cancer (MBC) is rare, treatment recommendations are derived from results of trials in female patients (pts). Although, several studies have shown the superiority of third-generation aromatase inhibitors (AI) over tamoxifen in menopausal women with advanced breast cancer, the role of such molecules remains unknown in male pts. We report here the largest experience about the efficacy of AI in MBC pts with advanced disease and their impact on estradiol (E) levels. Methods: MBC pts were selected from the breast cancer database of the Centre Antoine-Lacassagne (Nice, France) as follows: Metastatic disease with at least one measurable or assessable non-measurable lesion, estrogen receptor (ER) and/or or progesterone receptor (PR) positive, availability of complete clinical and histological data, evidence of progressive disease at initiation of AI, receipt of at least one month of treatment with non steroidal (anastrozole, letrozole) or steroidal (exemestane) AI. Sex hormone levels were retrospectively assessed on serum samples from our institutional serum bank. Results: 15 pts entered the study. Median age was 68 (range 39–85). 7 pts received previous lines of hormonal therapy (median = 1) and 3 pts a previous line of chemotherapy before the introduction of AI. The best response was complete response in 2 pts (13%), partial response in 4 pts (27%), stable disease (SD) in 2 pts (13%) and progressive disease (PD) in 7 pts (47%). The median duration of objective response (OR) was 11.6 months (95% confidence interval [CI] 7.6–15.5). At the time of analysis, 8 pts (53%) had died and 7 (47%) were still alive. The median PFS and OS were 4.4 months (95% CI 0.1–8.6) and 33 months (95% CI 18.4–47.6) respectively. The 1-year PFS and OS rates were 20% (95% CI 9.7–30.3) and 84.6% (95% CI 74.6–94.6), respectively. 9 out of 11 pts with available samples had E levels less than the lower limit of the assay during AI treatment. Among the 9 pts with E level decrease, four had OR, one had SD, and four had PD. 1 pt had E levels higher than the upper limit of the assay during AI treatment. This pt showed disease progression. Further data on FSH and testosterone levels will be presented at the meeting. Conclusions: AI are active in MBC pts. This activity is correlated with a significant reduction in E levels.

No significant financial relationships to disclose.

Long-term follow-up and factors of survival of HER-2 positive breast cancer patients treated either by neoadjuvant trastuzumab docetaxel (TAXHER-S01 study) or by neoadjuvant trastuzumab docetaxel carboplatin (GETN[A]1 study)

e11507

Background: Almost 20% of breast cancers over express Her2, which is associated with a more aggressive phenotype and with a decreased survival. Nevertheless, trastuzumab (T) has been a revolutionary step in the adjuvant and in the metastatic treatments of Her2 positive breast cancers. Here, we focus on neoadjuvant T and try to determine the factors correlating with disease free survival and with overall survival in Her2 positive breast cancer treated with T based neoadjuvant chemotherapy. Methods: Data from two published T based neoadjuvant phases II were used: the TAX-HER trial which studied the use of 6 courses of 3 weekly docetaxel with weekly neoadjuvant T (scheme TH) (Coudert et. al. Annals of Oncology 2006) and the GET(N)A-1 trial which studied the use of 6 courses of 3 weekly docetaxel and carboplatin along with weekly neoadjuvant T (scheme TCH) followed by 3 weekly adjuvant T (Coudert et. al. JCO 2007). Moreover, additional patients from our institution and treated by neoadjuvant TH and adjuvant T were included. Survival curves were estimated using Kaplan-Meier methods and compared by log-rank test. Results: Data was available for 128 patients. 62 patients (48.4%) received neoadjuvant TH from whom 39 did not receive adjuvant T. 66 (51.6%) received neoadjuvant TCH and adjuvant T. Tumors characteristics were as followed: 65 (50.7%) SBR 1–2, 54 (42.19%) SBR 3, 49 (38.28%) hormonal receptors (RH) negative and 72 (56.25%) RH positive. The rate of pathological complete response (pCR) (Chevalier 1/2) was 39.6%. Overall survival (OS) for the entire cohort was 74,8 months. Relapse was defined as local, regional, metastatic relapse or death. Survival without relapse (SR) was 74.8 months. No difference was noted in OS and in SR according to the type of chemotherapy, TH or TCH. pCR did significantly influence SR (p = 0. 03) and survival without local recurrence (SLR) (p = 0.04) but neither OS nor survival without metastatic relapse (SMR). Multivariate analysis demonstrated that OS was correlated with node response (as defined by sataloff grade NA or NB) (p=0.0275) and the use of hormonal therapy in RH positive tumors (p=0.0724).

[Table: see text]

Prognostic factors in 1,038 women with metastatic breast cancer

BACKGROUND

Treatment of metastatic breast cancer (MBC) remains palliative. Patients with MBC represent a heterogeneous group whose prognosis and outcome may be dependent on host factors. The purpose of the present study was dual: first, to draw up a list of factors easily available in everyday clinical practice requiring no sophisticated or costly methods and second, to provide results from a large cohort of women who underwent diagnostic and treatment at a single institution.

PATIENTS AND METHODS

From 1975 to 2005, a total of 1,038 women with MBC during their follow-up were included in this retrospective analysis. Patients were subsequently assigned to five groups according to the period of metastatic diagnosis.

RESULTS

It is shown that age at initial diagnosis, hormonal receptor status and site of metastasis are the most relevant prognostic factors for predicting survival from the time of metastastic occurrence. It is also shown that a metastasis-free interval is an easily and immediately available multifactorial prognostic index reflecting the multiparametric variability of the disease.

CONCLUSION

These fundamental observations may assist physicians in evaluating the survival potential of patients and in directing them toward the appropriate therapeutic decision.

Role of the HER2 [Ile655Val] genetic polymorphism in tumorogenesis and in the risk of trastuzumab-related cardiotoxicity

BACKGROUND

To examine the impact of a frequent her2 gene polymorphism (Ile655Val) on tumor growth and on the pharmacodynamics of treatment by trastuzumab.

PATIENTS AND METHODS

Experimental study: The growth characteristics of cells expressing the Ile or Val isoform were examined in vitro and after injection into nude mice. The effect of trastuzumab was determined in both experimental models. Clinical study: 61 patients with advanced breast cancers and treated by trastuzumab were genotyped for HER2 by PCR-RFLP. The influence of HER2 genotype on the trastuzumab treatment was examined.

RESULTS

Experimental study: HER2-expressing cells acquired the characteristics of tumor cells. The Val isoform-expressing cells showed the highest growth capacity and developed aggressive tumors sensitive to trastuzumab. Clinical study: There was no link between tumor response or survival and HER2 genotype. All cases of treatment-related cardiotoxicity were found in the Ile/Val group and there was no cardiac toxicity in the Val/Val and Ile/Ile patients.

CONCLUSIONS

This study establishes a clear-cut difference between the two HER2 isoforms regarding their tumorogenic potential with an advantage for the Val/HER2 isoform. In breast cancer patients treated with trastuzumab, the presence of a Val allele may constitute a risk factor for cardiac toxicity.

Early versus late local recurrences after conservative treatment of breast carcinoma: differences in primary tumor characteristics and patient outcome

OBJECTIVES

To investigate whether some aspects of patient or tumor characteristics influence the timing of local recurrence (LR) in breast cancer treated conservatively, and to assess the impact of the timing of LR on patient outcome.

METHODS

A retrospective analysis was conducted on patients treated with conservative breast surgery followed by radiotherapy for breast carcinoma who developed LR. Out of 2,008 cases treated in our Institute between 1977 and 2002, 180 ipsilateral LR were observed. Of these, 46 LR were observed within 36 months after treatment, called early local recurrence (ELR), 44 developed between 37 and 60 months, called medium local recurrence (MLR), and 90 occurred after 60 months, called late local recurrence (LLR). Patient and tumor characteristics were analyzed in the 2 groups and compared.

RESULTS

Primary tumors >20 mm were more frequently found in patients with ELR (31%) than in patients with LLR (17%, p = 0.047). Grade 3 tumors were more often encountered in patients with ELR than in patients with LLR (27 versus 7%, p = 0.0002). Patients with ELR more frequently had tumors with negative estrogen receptors than patients with LLR (37% versus 6%, p < 0.0001). There was no statistically significant difference in the axillary lymph node (LN) status between patients with ELR and those with LLR (35 and 23% of positive LN, respectively, p = 0.24). Tumor size, grade, LN status, hormone receptors and the timing of LR affected the specific survival (SS) from initial surgery. On multivariate analysis, only LN status and the timing of LR retained an independent prognostic value, with an odds ratio of 6.7 for ELR. After LR, the SS was also influenced by all of the above factors, and on multivariate analysis, LN status, hormone receptors and the timing of LR were independent predictors with an odds ratio of SS of 2.50 in case of ELR (p = 0.006). The 5-year SS after LR for ELR, MLR and LLR were 55.8, 74.8 and 79.5%, respectively.

CONCLUSIONS

Unfavorable tumor characteristics such as big size, high grade, lack of hormone receptors, but not LN status, were associated with ELR. These findings suggest that patients with such aggressive tumor characteristics who do not recur early will have a lower risk of LLR than patients with more favorable factors.

Concomitant weekly carboplatin (CB) and paclitaxel (P) with pelvic radiotherapy (RT) for the treatment of advanced cervical cancer (ACC): A FNCLCC gynecologic group phase I trial

5542

Background: Standard primary treatment for locally ACC is RT with concomitant chemotherapy (CT). CB and P are radiosensitizers with in vitro synergistic action. Methods: Patients (pts) with FIGO stage IIB-IVA negative paraaortic lymph nodes cervical cancer were treated with 6 weekly cycles of CT during pelvic RT (45 Gy) and brachytherapy (BT) according to Table 1 . Each dose escalation step followed a 30-day period of observation on cohorts of 3 to 6 pts depending on dose limiting toxicity (DLT): toxic death; garde (G) 4 neutropenia > 1 week; G 4 toxicity (other hematologic or non-hematologic); any toxicity requiring = 1 week delay in RT, or > 2 dose reductions of CT, or G 3/4 hematologic toxicity > 3 weeks after treatment’s end; unendurable G 3 non hematologic toxicity. Results: 23 pts were included by 5 centers in 5 dose levels (L). Stage distribution: IIB (10), III (11), IVA (2); 20 epidermoid and 3 adenocarcinoma; ECOG: 0 (16), 1 (7). 22 pts received the 6 planned cycles. Median dose of irradiation was 45 Gy (43.2–50) with no toxicity related interruption. 17 pts underwent BT, 2 had hysterectomy and 1 received complementary external irradiation 12 Gy. CT dose reduction was necessary in 4 pts (cycle 5 or 6) and cycles postponed for 10 pts (cycle. 5 or 6). One pt experienced paclitaxel allergy at L1. G 3 anemia and/or neutropenia were reported in 11 pts and G 4 neutropenia = 1 week in 2 pts. Radiodermatitis occurred in 5 pts, asthenia in 3 and nausea in 1. One DLT was observed: unendurable G 3 asthenia + G 3 neutropenia and leucopenia at L3. Clinical and radiological complete response was obtained in 13 pts, 5 PRs and 2 SDs in 20 evaluable pts. Conclusions: Acceptable toxicity and optimal irradiation were possible at L4 in 7 pts. These doses are recommended for future phase II studies of concomitant CT/RT in ACC.

[Table: see text]

No significant financial relationships to disclose.

Home infusions of biphosphonate in cancer patients: a prospective study

The objective of the study was to determine outcome and satisfaction of cancer patients treated by home-infusions of biphosphonates. 107 patients entered the study and 97 of them chose to receive infusions of zoledronic acid (Z) in the home setting. Patient satisfaction and quality of care (QoC) were assessed by a 22-item questionnaire. Changes from baseline were determined for bone pain using a 0-10 cm visual analogue scale pain score (VAS). Patients expressed a high level of satisfaction specifically with regard to nursing care. Seventy patients experienced a significant decrease in the median pain score during the home-therapy phase not due to an increased use of analgesic therapy (P = 0.03). Z was well tolerated with no major adverse events. The authors conclude that home infusions of biphosphonates, on the condition that the supportive care team is well-organized, is a safe procedure that could be advantageous for patients by increasing satisfaction and compliance with treatment.

Clinical significance of brain metastases occurrence in HER2 overexpressing metastatic breast cancer patients treated with trastuzumab

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Background: Recent data report that HER2 overexpressing metastatic breast cancer patients (HER+ MBC pts) treated with trastuzumab (T) have a high rate of Brain metastasis (BM). This study aimed to evaluate the prognostic significance of BM occurrence and the related clinical outcome in a specific patient population. Methods: All the HER+MBC patients treated with trastuzumab (with or without chemotherapy) between 09/1999 and 12/2004 were included in this study. Results: A total of forty three patients were enrolled into the study cohort. The median follow-up was 48 months (range, 11–166). Fifteen patients (35%) developped BM. The median interval from the the first MBC event to BM was 18 months (range, 1–65). In multivariate analysis; younger age was the only factor associated with BM occurrence (46 versus 57 years; p = 0.01). Patients with BM tend to have a longer median duration of response to T than patients without BM (16 months versus 13 months; p = 0.1). At the time of BM appearance, 6 of the 15 patients (40%) were still responding or had achieved extracranial stable disease while receiving trastuzumab. Twelve out of 15 (80%) pts received a whole-brain radiation therapy, and 8 pts continued to receive trastuzumab until extracranial disease progression. The median overall survival for patients diagnosed with BM was 10 months (range, 2–42). At three-year, there was no significant difference in overall survival rates between the two groups. The 3-YS was 63.5% and 66.7% for pts with or without BM, respectively; (p = 0.7). Conclusions: The BM occurrence in HER2+ MBC pts treated with Trastuzumab is not linked to tumour resistance, but likely related to the T inability to cross the blood-brain barrier. There is no impaired survival for these pts treated with effective and appropriate therapy.

[Table: see text]

Effect of pregnancy, in the year prior and after treatment for breast carcinoma, on survival and recurrence in women with breast cancer younger than 35 years. GETNA GROUP

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Background: The goal of this study was to assess the effect of pregnancy on the subsequent risk of recurrences after treatment for breast carcinoma, adjusted on established prognostic factors Methods: Between 1990 and 1999, 908 patients aged under 35 years old were treated for a non metastatic and unilateral invasive breast carcinoma in eight french hospitals, members of the GETNA association. The median follow-up period was 87 months. Mean age was 31.4 years old. Estrogen receptor (ER) status, lymph node involvement, tumor size, histological grade and pregnancy were evaluated as potential risk factors for recurrence and death in a multivariate analysis. A modified model was constructed using the four independent variables derived from the previous multivariate Cox model and the annual risk of death and recurrences were studied. Results: Women who gave birth within one year prior to diagnosis (n=105, 11, 8%) were more likely to have axillary node positive (> N1:48%, vs 35%, p=0.009) important tumor size (>T2:75% vs 55%, p=0.0002), and ER negative (54%, vs 42%, p=0.031). In univariate analysis, pregnancy the year before carcinoma diagnosis increased the risk of death, HR=1.5 [1.05–2.20] (p=0.028) and local recurrence, HR=1.71 [1.06–2.76] (p=0.027). In multivariate analysis, only influence on local recurrence is confirmed, HR=1.75 [1.08–2.84] (p=0.006). Patients who experienced a pregnancy after diagnosis and treatment (n=118, 13.4%) did not tend to have better prognosis regarding axillary node positive (> N1:71%, vs 61%, p=0.051), tumour size (> T2:53.4% vs 59.2%, p=0.49), ER negative (ER:44.2% vs 43.6%, p=0.92) and were significantly younger (<30 years old 52.5% vs 28%, p<10−4). The overall survival after five years was 97% for women who experienced a pregnancy and only 80% for those who did not (p< 0.0001). Conclusions: In this large study population, pregnancy was not associated with poorer survival and the healthy mother effect was studied. For the purpose of advising women on the decision to go forward with pregnancy, was studied after the diagnosis and treatment of breast carcinoma, the annual risk of recurrences. Study granted by Sanofi-Aventis. Acknoledgements to OSMO for its operational support.

No significant financial relationships to disclose.

Long median survival with capecitabine (X) single-agent therapy for patients (pts) with anthracycline- and taxane-pretreated metastatic breast cancer (MBC)

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Background: X (Xeloda) is an oral fluoropyrmidine with consistently high activity in MBC, a good safety profile with little myelosuppression and no alopecia, and the convenience of oral administration. The addition of X to docetaxel in anthracycline-pretreated pts also increases survival. This non-randomized phase II study was conducted to evaluate the efficacy, safety and impact on quality of life (QoL) of X in pts with MBC pretreated with anthracyclines and taxanes. Main findings from this trial have been published previously [Fumoleau et al. Eur J Cancer 2004;40:536–42]. Here we present mature data after a follow-up of 48 months. Methods: Pts with anthracycline- and taxane-pretreated MBC received X 1250 mg/m2 twice daily on days 1–14 every 3 weeks for a median of 6 cycles (range 1–15). Results: Baseline characteristics of the 126 pts enrolled were typical of a pretreated MBC population. X achieved complete/partial response or stable disease in 63% of patients (overall response rate, 28%). Median time to progression was 4.9 months (95% CI: 4.0–6.4).Median duration of response was 5.9 months (95% CI: 4.5–12.7). The only grade 3/4 events occurring in ≥ 10% of patients were diarrhea (10%) and HFS (21%). The most common grade 3/4 laboratory abnormality was granulocytopenia (14%). After a follow-up of 48 months, 8 patients are still alive. Updated median overall survival is 15.9 months (95% CI: 13.5–21.3). 1-, 2- and 3-year survival rates are 63%, 37% and 17%, respectively. QoL assessment showed that X treatment was associated with an increase in mean Global Health Score up to cycle 6, with the increase maintained at subsequent evaluations. Conclusions: X is highly active in patients with anthracycline- and taxane-pretreated MBC, leading to a long median survival of 15.9 months. X is also well tolerated and improves QoL.

[Table: see text]

Docetaxel (Do) and liposomal pegylated doxorubicin in metastatic breast cancer (MBC) patients (pts): The French GINECO group experience

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Background: Taxanes and anthracyclins are among the most effective agents in MBC. Ca has a favourable cardiac toxicity profile and we tested Ca in combination with Do. Methods: Two successive Ca-Do regimens (Reg) were evaluated in first line MBC pts with performance status ≤ 2, and good organ function including normal MUGA scan. Reg A (n = 53 pts): Ca 35 mg/m2/d1 q4wks + Do 40 mg/m2/d1 q2wks according to previous phase I study results (Guastalla JP et al, Proc Am Soc Clin Onc 2004) and Reg B (n = 14 pts): Ca 30 mg/m2/d1 + Do 75 mg/m2/d2 every 3wks (Alexopoulos A et al, Ann Oncol 2004). Pyridoxine (250 mg/d) was given continuously during treatment (Tt). Results: The 67 pts had a median age of 58 yrs (range 37–77 yrs); others characteristics (%): ER+ (75), PR+ (51), HER2+ (9), adjuvant anthracyclin (54) and hormonotherapy (60), visceral disease (78). Both regimens induced unbearable toxicities (Tox) leading to premature stopping of the trial. Dose reduction, Tt delay and early stopping due to Tox were noted (% pts) in A:68, 36, 48 and B:57, 64, 54. Mucositis-skin Tox was the most severe Tox (% Gr2/3; A:40/15, B:43/21) and was observed in 21 and 40% of pts at cycle 2 and 4. Hematotoxicity was worse in reg B: Gr3/4 neutropenia (A:28/9, B:14/57), anemia (A:0/0, B:7/7) and thrombopenia (A:0/0, B:14/0), febrile neutropenia (A:6, B:14), Gr2–3 infection (A:13, B:28). Others Gr2–3 toxicities (> 10%) included alopecia (A:64, B:78), fatigue (A:54, B:57), nausea/vomiting (A:19, B:50). Three pts had a reduction of LVEF without clinical cardiac toxicity Conclusions: The combination of Do and Ca according to the 2 schedules tested in this study induced an unexpected high rate of mucositis and skin toxicity.

No significant financial relationships to disclose.

Interstitial brachytherapy as the sole treatment for tongue metastasis from breast carcinoma

Breast carcinoma metastasize more frequently to the bone, liver lung and brain as compared to other anatomical sites. As such, advanced breast tumours with secondaries involving the rarer sites often pose when a therapeutic challenge for the clinician to find a good balance between offering the most effective therapy and its potential toxicity. We report the first case of tongue metastasis from breast cancer that was successfully treated with interstitial brachytherapy, resulting in good local control and no severe side effects.

Prognostic value of S-phase fraction in 920 breast cancer patients: focus on T1N0 status

The aim of this study was to reexamine the prognostic role of tumor cell kinetics measured by S-phase fraction (SPF) and to establish its clinically relevant threshold values. SPF was determined by flow cytometry in a group of 920 consecutive breast cancer patients, all followed at our institute for 10 years (1988 to 1998). Mean age was 60.5 years (27-89 years). Median follow-up was 63 months (3-150 months). All patients had initial surgical treatment. SPF quartiles were: Q1=3.08%, median value = 5.98%, Q3=10.22%. A significant difference in overall specific survival was obtained between two populations divided by a cutoff at Q1 (p < 0.0001). A multifactorial analysis including SPF and known prognostic factors such as tumor size, node status, histological grade, ER and PR status was performed using the Cox model in a population of 719 patients: univariate analysis showed that each of these factors had significant influence on overall survival. Multivariate analysis selected three of them, ranked by decreasing order of hazard ratio (HR) value: SPF (HR: 3.88, p < 0.001), tumor size (HR: 2.49, p < 0.001) and nodal status (HR: 2.28, p < 0.001). In addition, when tumors were stratified according to SPF quartile values, there were statistically different overall survival curves in patients with small tumors (< 2 cm) and in axillary node-negative patients.

Multicentre, phase II study evaluating capecitabine monotherapy in patients with anthracycline- and taxane-pretreated metastatic breast cancer

Treating patients with anthracycline- and taxane-pretreated metastatic breast cancer (MBC) represents a significant challenge to oncologists. The tumour-activated oral fluoropyrimidine, capecitabine, is the only treatment approved for these patients. Our study evaluated the efficacy, safety and impact on quality of life (QOL) of capecitabine in this setting. Patients (n=126) with anthracycline- and taxane-pretreated metastatic breast cancer received capecitabine 1250 mg/m(2) twice daily, days 1-14, followed by a 7-day rest period. Median time to progression was 4.9 months (95% Confidence Interval (CI): 4.0-6.4). Thirty-five patients (28%) achieved an objective response (95% CI: 20-36%), including five (4%) complete responses. Median overall survival was 15.2 months (95% CI: 13.5-19.6 months). Capecitabine demonstrated a favourable safety profile, with a low incidence of treatment-related grade 3/4 adverse events. The most common adverse events were hand-foot syndrome and gastrointestinal effects. QOL assessment showed that capecitabine treatment was associated with an increase in mean Global Health Score. Capecitabine is active, well tolerated and improves the QOL of patients with anthracycline- and taxane-pretreated metastatic breast cancer. Based on the consistently high activity demonstrated in clinical trials, capecitabine has become the reference treatment in this setting.

Imaging in evaluation of response to neoadjuvant breast cancer treatment benefits of MRI

PURPOSE

To compare the value of conventional imaging modalities and MRI for determination of response to neoadjuvant chemotherapy for breast cancer.

MATERIAL AND METHODS

Sixty tumors (53 ductal carcinomas, seven invasive lobular carcinomas) in 51 patients were evaluated by physical examination, mammography, ultrasound, and MRI at baseline before therapy, after three courses of chemotherapy, and after six courses prior to surgery. Data from physical examination and imaging studies were compared to histopathological findings.

RESULTS

(i) MRI was the most reliable technique for evaluation of residual tumor size; this parameter was correctly estimated in 63% of cases by MRI versus, respectively 52, 38, and 43% by physical examination, mammography, and ultrasound, (ii) MRI correctly identified the response to chemotherapy in all cases of complete response (five cases), and in 45/55 cases of partial response (43 cases) or no response (12 cases), and (iii) among the 32 patients who underwent a mastectomy, MRI correctly revealed the multifocal nature of the disease for 12/15 multifocal lesions found at histological examination; both mammography and sonography were accurate in only six of the 15 cases.

CONCLUSION

MRI appears to be a valuable technique for assessment of response to chemotherapy and identification of multifocal disease prior to surgery.

[132 grams of tamoxifen: ultrasonographic and MRI appearance of endometrial carcinoma]

Endometrial carcinoma is a rare iatrogenic complication due to the adverse estrogenic like effect of Tamoxifen on the uterine mucosa. We report the delayed case of an endometrial carcinoma after an unusual twleve year long daily administration of Tamoxifen (cumulative dose = 131 g). Endovaginal contrast ultrasound examination (Levovist, Schering, Germany) and MRI appearances are described.